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(3) Musculoskeletal Imaging > S2_L1 Anatomy, X-ray, CT Scan, & MRI of the Lumbar and Sacral Spine > Flashcards

S2_L1 Anatomy, X-ray, CT Scan, & MRI of the Lumbar and Sacral Spine Flashcards

1
Q

It is the biggest and thickest portion of all the spinal regions. However, this region may become smaller due to degeneration or fractures.

A

Lumbar spine

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2
Q

TRUE OR FALSE: The lumbar spine is assessed cephalocaudally.

A

False, it’s assessed caudocephalically

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3
Q

Modified TF
A. The L4-L5 and L5-S1 IV discs are wedge-shaped and thicker anteriorly.
B. L4-L5 is the most wedge-shaped IV disc in the lumbar spine.

A

TF

B: L5-S1 is the most wedge-shaped

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4
Q

Modified TF
A. The primary supports of the sacroiliac joint are the sacrospinous and sacrotuberous ligaments.
B. These two ligaments form the greater and lesser sciatic foramina.

A

FT

A: The interosseous ligaments (posterior & anterior sacroiliac ligaments) are the primary supports. The sacrospinous and sacrotuberous ligaments are additional supports of the SI joint.

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5
Q

TRUE OR FALSE: In pelvic fractures, disruptions of the primary supports of the SI joint cause narrowing and instability, leading to an unstable pelvic brim.

A

False, disruptions of the primary supports of the SI joint cause widening and instability, leading to an unstable pelvic brim.

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6
Q

Scottie Dog

  1. Foreleg
  2. Ear
  3. Hind leg
  4. Tail

A. Superior articulating process
B. Superior articulating process (opposite)
C. Inferior articulating process
D. Inferior articulating process (opposite)

A
  1. C
  2. A
  3. D
  4. B
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7
Q

Scottie Dog

  1. Neck
  2. Body
  3. Eye
  4. Nose

A. Pedicle
B. Transverse Process
C. Pars interarticularis
D. Lamina and spinous process

A
  1. C
  2. D
  3. A
  4. B
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8
Q

Refers to the narrow portion in the posterior pillar of the vertebra, located in between the superior and inferior articular facets.

A

Pars interarticularis

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9
Q

Modified TF
A. The right and left oblique views are taken with a central ray passing through L4-L5 and a pillow wedge to allow obliquity.
B. The image of a Scottie dog can be seen on an oblique radiograph of the lumbar spine.

A

FT

A: Right and left oblique views are taken with a central ray passing through L3-L4 and a pillow wedge to allow obliquity.

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10
Q

TRUE OR FALSE: The sacrum is visualized on a basic lumbar spine series, but it can also be radiographed as a separate examination if it is the area of interest.

A

True

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11
Q

Modified TF
A. The Ferguson’s angle is measured from the sacral base and a vertical line at the anterior edge of sacrum.
B. The Barge angle is measured from the sacral base and a horizontal line at the anterior edge of sacrum.

A

FF

A: The Ferguson’s angle is measured from the sacral base and a horizontal line at the anterior edge of sacrum.
B: The Barge angle is measured from the sacral base and a vertical line at the anterior edge of sacrum.

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12
Q

Lumbosacral Angle Average Values

  1. Ferguson’s angle: __
  2. Barge angle: __
A
  1. Ferguson’s angle: 41º
  2. Barge angle: 53º
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13
Q

Modified TF
A. In the lateral view, the individual is lying in the R/L decubitus position and the central ray passes through L3-L4.
B. The central ray always passes perpendicular to the image receptor in the lateral view.

A

TT

Note: The central ray should always be perpendicular in this view, if not it will be oblique.

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14
Q

The following are the basic projections of the routine radiologic evaluation of the lumbosacral spine, except:
A. Anteroposterior
B. Lateral
C. Right and left obliques
D. Lateral L4-L5
E. None

A

D. Lateral L4-L5

Correct answer is Lateral L5-S1, which is taken in the lateral decubitus position and when focusing on the sacroiliac joint and this area of the lumbosacral spine.

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15
Q

This ligament provides the major restraint against excessive shear between L5 and the sacrum.

A

Iliolumbar ligament

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16
Q

MRI of the LS Spine: Indication or Contraindication

  1. Syringohydromyelia
  2. Intramedullary tumors, intradural masses
  3. External or implanted cardiac pacemakers
  4. Ferromagnetic intracranial aneurysm clips
  5. Meningeal abnormalities
A
  1. I
  2. I
  3. CI
  4. CI
  5. I
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17
Q

MRI of the LS Spine: Indication or Contraindication

  1. Extensive tattoos
  2. Neurostimulators
  3. Spinal vascular malformations and/or cause of occult subarachnoid hemorrhage
  4. Intrinsic spinal cord pathology, demyelinating and inflammatory conditions
  5. Cochlear implants (hearing aids on inner or outer ear)
A
  1. CI (d/t iron and lead content)
  2. CI
  3. I
  4. I
  5. CI
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18
Q

MRI of the LS Spine: Indication or Contraindication

  1. Treatment fields for radio tx
  2. Disc space infections, osteomyelitis, epidural abscess
  3. Extradural soft tissue and body neoplasm
  4. Ferromagnetic foreign bodies or electronic devices
  5. Pre-op assessment for vertebroplasty or kyphoplasty
A
  1. I
  2. I
  3. I
  4. CI
  5. I
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19
Q

MRI of the LS Spine: Indication or Contraindication

  1. Intradural extramedullary masses, leptomeningeal disease
  2. Nonremovable body piercing
  3. Degenerative disc disease
  4. Post op intraspinal fluid or post-op soft tissue changes
  5. Congenital spinal abnormalities/scoliosis
A
  1. I
  2. CI
  3. I
  4. I
  5. I
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20
Q

TRUE OR FALSE: Post-op open reduction internal fixation done using titanium screws, plates, or rods is compatible with MRI.

A

True

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21
Q

MRI typical pulse sequences
1. Defines abnormal fluid
2. Defines anatomical structures
3. Recommended for viewing of infection, trauma, & tumors
4. Abnormal fluid edema

A. T1 weighted sequences
B. T2 weighted sequences

A
  1. B
  2. A
  3. B
  4. B
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22
Q

Modified TF
A. The MRI is commonly used for tumors, masses, and other chronic conditions.
B. The CT scan is more used for acute and life-threatening conditions in trauma radiology.

A

TT

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23
Q

Modified TF
A. The anterior surface of the sacral spine is smooth & concave.
B. It contains 5 pairs of anterior sacral foraminae where the anterior rami of the sacral nerves exit.

A

TF

B: It contains 4 pairs of anterior sacral foraminae where the anterior rami of the sacral nerves exit.

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24
Q

Sacral Spine parts

  1. Failed union of the 5th sacral laminae
  2. Large masses of bone lateral to sacral body segments
  3. Superior End
  4. Inferior End; fused with coccyx distally
  5. Articulates with the ilium (base of iliac wing) and forms the SI joint

A. Ala wing
B. Base
C. Apex
D. Sacral hiatus

A
  1. D
  2. A
  3. B
  4. C
  5. A
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25
Q

Modified TF
A. The sacroiliac joint is formed primarily from the upper 5 sacral vertebrae.
B. The sacrum is the fusion of 3 sacral vertebrae, shaped like an inverted triangle.

A

FF

A: The sacroiliac joint is formed primarily from the upper 3 sacral vertebrae.
B: The sacrum is the fusion of the 5 sacral vertebrae, shaped like an inverted triangle.

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26
Q

Modified TF
A. The posterior surface of the sacral spine is rough and corrugated.
B. The midline sacral crest is present on the posterior surface, made up of fused sacral transverse processes.

A

TF

B: The midline sacral crest is present on the posterior surface, made up of fused sacral spinous processes.

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27
Q

Modified TF
A. The facets of the lumbar spine are coronally oriented.
B. With the exception of the facets of L5 that are sagittally oriented.

A

FF

A: The facets of the lumbar spine are sagittally oriented.
B: L5 facets are coronally oriented

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28
Q

Basic Protocols of LS Spine

  1. Takes approx. 20-30 slices per vertebra
  2. Extends from T12 to SI joints (Lower thoracic spine to SI joints)
  3. After development of film, you can request to post process to view in other angles
  4. Axial and sagittal images are the standard, coronal is infrequently obtained

A. Basic CT protocol
B. Basic MRI protocol
C. Both
D. Neither

A
  1. A
  2. C
  3. A
  4. B
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29
Q

Basic Protocols of LS Spine

  1. Data are viewed as axial slices, but are reformatted into sagittal and coronal planes or 3D images (especially for severe fractures)
  2. Each image has its own scanning procedure
  3. Has a window or level setting to allow for demonstration of bone and soft tissue abnormalities
  4. The choice of cut is inputted before the procedure, and the cut cannot be manipulated afterwards

A. Basic CT protocol
B. Basic MRI protocol
C. Both
D. Neither

A
  1. A
  2. B
  3. A
  4. B
30
Q

Indication for CT scan (Yes or No)

  1. Infectious process of the spine
  2. Acute trauma in adults
  3. Degenerative conditions and OA
  4. Neoplastic conditions and their complications
  5. Follow-up of known abnormality
A
  1. Yes
  2. Yes
  3. Yes, if MRI is not available/contraindicated
  4. Yes
  5. No, this is an indication for x-ray
31
Q

The following are indications for CT scan of the LS spine, except:
A. Image guidance for spinal interventions like biopsy and injections
B. Post-operative evaluation of bone graft or instrument fusion
C. Inflammatory lesions and crystal deposition diseases
D. Congenital or developmental spine abnormalities like scoliosis and spondylolysis
E. None

A

E. None

32
Q

Case: You have a 57 y/o male patient complaining of headaches, muscle weakness, and pain in the neck, arms, and back. You suspect a spinal cord syrinx, or possibly an intrathecal mass. The patient’s chart also shows record of a cardiac pacemaker that was implanted 1 year ago. Which radiologic evaluation is best to use for the patient?
A. X-ray
B. CT Scan
C. MRI
D. All
E. None

A

B. CT Scan

Spinal cord syrinx and other intrathecal masses are indications for CT scan when MRI is contraindicated (e.g., due to cardiac pacemaker).

33
Q

Modified TF
A. The spinous processes of the lumbar spine are large, blunt, vertically inclined.
B. The lumbar vertebral bodies are large, increase in size from the first to the fifth vertebra.

A

FT

A: The spinous processes of the lumbar spine are large, blunt, horizontally inclined.

34
Q

Modified TF
A. In an axial CT scan, the liver and spleen can be seen in the same slice along with T12 and the 12th ribs.
B. The kidney is noted in the slice along with the L1 body, the L1 inferior articulating process forming L1-L2 facets joints, and the L1 spinous process.

A

TT

35
Q

Modified TF
A. In an axial CT scan, superior articular facets are seen on the same horizontal plane as the transverse processes.
B. The iliac crests can be seen on either side at the level of L5.

A

TT

36
Q

TRUE OR FALSE: In a coronal CT scan, the mid to lower lumbar vertebrae appear first due to the lordotic curve, which places them more anterior.

A

True

37
Q

TRUE OR FALSE: All facet joints at all levels can be displayed in a single slice.

A

False

38
Q

Routine Radiologic Evaluation: Lateral View

Modified TF
A. IV disc spaces are wedge-shaped, but the L5-S1 shape is more wedged than L4-L5 and the rest are almost equal in size.
B. The vertebral body is box-like, and osteophytes at the margins indicate degenerative changes have occurred.

A

TT

39
Q

Routine Radiologic Evaluation: Lateral View

Modified TF
A. The pedicles are superimposed and form 2 pedicles.
B. If there is only 1 pedicle present, this indicates a curved spine with misaligned vertebral bodies.

A

FF

A. The pedicles are superimposed and form only 1 pedicles.
B. If there were 2 pedicles present, this indicates a curved spine with misaligned vertebral bodies.

40
Q

Routine Radiologic Evaluation: Lateral View

Modified TF
A. IV foramina are imaged as radiolucent ovals.
B. The foramina from L1-L2 to L3-L4 are clear, big, and wide radiolucent ovals, however, the foramina from L4-L5 to L5-S1 are typically smaller and narrowed.

A

TF

B. The foramina from L1-L2 to L4-L5 are clear, big, and wide radiolucent ovals, however, the foramina from L5-S1 are typically smaller and narrowed.

Note: Small and narrowed foramina for L5-S1 is normal, but very small dots or “tuldok” are pathological, indicating possible constriction in the area.

41
Q

Routine Radiologic Evaluation: Lateral View

  1. Spinolaminar line (only seen in lateral view)
  2. Anterior vertebral body line
  3. Posterior vertebral body line

A. Vertebral Line 1
B. Vertebral Line 2
C. Vertebral Line 3

A
  1. C (junction between spinous process and lamina)
  2. A
  3. B

Note: Vertebral lines should be aligned. The spinal canal is seen from lines 2-3 and disruptions in these lines may cause canal stenosis.

42
Q

Routine Radiologic Evaluation: Lateral View

Modified TF
A. General disruption of the vertebral lines can be attributed to fractures, dislocations, spondylolisthesis, or spinal stenosis.
B. Forward translation of vertebral bodies result in spondylolysis.

A

TF

B. Forward translation of vertebral bodies result in spondylolisthesis.

43
Q

Routine Radiologic Evaluation: Lateral L5-S1

Modified TF
A. The vertebral lines (1-3), IV disc spaces, and lumbosacral angles can be viewed in the lateral L5-S1 projection.
B. The vertebral lines should have a smooth and continuous transition at the LS junction.

A

TT

Note: A step-off in the vertebral lines may indicate fracture, dislocation or spondylolisthesis (when the vertebral bodies move forward or backward).

44
Q

Routine Radiologic Evaluation: Lateral L5-S1

Modified TF
A. IV disc spaces present as dark, radiolucent areas due to the vacuum phenomenon, where air is trapped in the IV disc.
B. A herniated disc or osteophytes (sign of arthritis of the spine or spondylosis) would cause narrowing of the disc spaces.

A

TT

Note: The vacuum phenomenon is commonly seen in osteoarthritis of the spine and spondylosis.

45
Q

Routine Radiologic Evaluation: AP view

Modified TF
A. Sacroiliac joints are compared to evaluate joint space thickness bilaterally, which must be equal.
B. Joint thickness is seen on imaging as a radiodense line.

A

TF

B. Joint thickness is seen on imaging as a radiolucent line.

Note: During imaging, the patient may be positioned with the knees in extension to preserve lumbar lordosis or in flexion to eliminate lordosis.

46
Q

Routine Radiologic Evaluation: AP view

Modified TF
A. The facets cast a butterfly shadow, where the articular surfaces are seen as shadows.
B. The psoas muscle also casts a shadow (psoas shadow), imaged as a radiolucent line extending from the transverse processes and anterolateral vertebral bodies diagonally.

A

TT

Note: An obliteration of the psoas shadow signifies an hematoma or abscess. An abscess in the psoas shadow may be caused by conditions such as infection of the spine (Pott’s Disease/TB of the spine).

47
Q

Routine Radiologic Evaluation: AP view

Modified TF
A. The vertebral bodies should be aligned and form a single vertical column with well-preserved intervertebral joint spaces.
B. The vertebral bodies are square-shaped and should be the same size moving down the column.

A

TT

48
Q

Routine Radiologic Evaluation: AP view

Modified TF
A. The spinous processes should be in the midline and equidistant from other spinous processes.
B. An increased interval between spinous processes at one level signifies a torn anterior ligament complex; and rotational components also occur when the spinous processes are deviated from midline.

A

TF

B: An increased interval between spinous processes at one level signifies a torn posterior ligament complex

49
Q

Routine Radiologic Evaluation: AP view

Modified TF
A. The central ray passes perpendicular to the image receptor through L3-L4 only.
B. The pedicles should be equidistant on either side of teardrop-shaped spinous processes, seen as circles on the vertebral bodies.

A

TT

50
Q

Routine Radiologic Evaluation: AP view

Modified TF
A. Misaligned pedicles signify fractures or dislocations.
B. Misalignments are commonly seen in scoliotic patients, where 1 side is closer to the spinous process (meaning it is not in midline) and the other side is farther, indicating a rotated spine.

A

TT

51
Q

CT Scan Radiological Observations

  1. For fractures evaluation to determine fracture fragment position
  2. To check facet joint appearance
  3. To check spinal canal diameter from T12-L5
  4. To check patency of canal and disc space height

A. Axial plane
B. Sagittal plane
C. Coronal plane

A
  1. C
  2. B
  3. A
  4. B

Note: More posterior coronal cuts allow for more field of vision for the clinician.

52
Q

Routine Radiologic Evaluation: Lateral View

TRUE OR FALSE: A gravity line extends from the body of L3 inferiorly and normally intersects the posterior third of the sacral base.

A

False, a gravity line extends from the body of L3 inferiorly and normally intersects the anterior third of the sacral base.

53
Q

CT Scan Radiological Observations

  1. To check vertebral alignment and configuration of the body
  2. To check that the posterior contour of disc is not constricting the central canal
  3. To check that the IV disc foramina are patent and free from disc material or bone

A. Axial plane
B. Sagittal plane
C. Coronal plane

A
  1. B
  2. A
  3. A

Note: If the axial image shows no pedicles, the image is at the level of the IV foramina, where the spinal nerves pass through.

54
Q

CT Scan Radiological Observations

Normal value of AP spinal canal diameter is ___, and transverse spinal canal diameter is ___.

A

Spinal canal
AP diameter: 15mm
Transverse diameter: 20mm

Note: The spinal canal diameter normally increases as you go down from T12 to L5. A diameter of <12mm is pathologic, indicating spinal stenosis (narrowing of spinal canal).

55
Q

TRUE OR FALSE: The transverse processes of the lumbar spine are slender, the pedicles short, and the laminae are broad and short.

A

True

56
Q

MRI Radiological Observations: Sagittal Plane

Modified TF
A. The anterior and posterior longitudinal ligaments are depressed in degenerative end plates or disc herniations.
B. The conus medullaris of the spinal cord ends at L3.

A

FF

A. The anterior and posterior longitudinal ligaments are elevated in degenerative end plates or disc herniations.
B. The conus medullaris of the spinal cord ends at L2.

57
Q

MRI Radiological Observations: Sagittal Plane

Modified TF
A. A thickened ligamentum flavum can cause stenosis and compression of the spinal canal.
B. Facet joint hypertrophy or osteophyte formation may impinge nerve roots.

A

TT

58
Q

MRI Radiological Observations: Sagittal Plane

TRUE OR FALSE: On T2 imaging of the spinal canal, the cauda equina, or “horse tail”, presents as dots within the white CSF.

A

True

59
Q

MRI Radiological Observations: Sagittal Plane

Modified TF
A. In the epidural space, a dark line should be noted, representing the dura mater that separates the CSF from the epidural fat pad.
B. In observing disc signal, height, and posterior contour, bulges can indicate annular bulging or nuclear herniation.

A

TT

Note: In observing the IV disc contour, bulging on the central or lateral recess indicates a herniated disc.

60
Q

MRI Radiological Observations: Sagittal Plane

TRUE OR FALSE: The vertebral bodies have a groove for the basi-vertebral artery.

A

False, vertebral bodies have a groove for the basi-vertebral vein

61
Q

Indications of Routine Radiologic Evaluation (Yes or No)

  1. Pain radiating into the legs
  2. Trauma involving the spine
  3. Hip pain, limping, or refusal to bear weight in pediatric patients
  4. Evaluation of scoliosis and kyphosis
  5. Evaluation of primary and secondary malignancies
A
  1. Yes
  2. Yes
  3. Yes
  4. Yes
  5. Yes
62
Q

Indications of Routine Radiologic Evaluation (Yes or No)

  1. Evaluation of/or suspected spinal abnormality
  2. Osteoporosis and compression fractures
  3. LOM, arthritis
  4. Follow-up of known abnormality
  5. Planned or prior surgery
A
  1. Yes
  2. Yes
  3. Yes
  4. Yes
  5. Yes
63
Q

TRUE OR FALSE: Any history of trauma to the spine will require an x-ray of the lumbosacral spine.

A

True

64
Q

Image Interpretations - Alignment (MRI or CT Scan)

  1. Coronal and sagittal cuts are used to assess normal spinal alignment or deviations
  2. Its sagittal slices are the best for assessing normal spinal alignment or deviations

A. MRI
B. CT Scan

A
  1. B
  2. A
65
Q

Image Interpretations - Disk integrity (MRI or CT Scan)

Used to check posterior and posterolateral disk margins on axial views as hernations alter posterior disk contour.

A. MRI: Disk Integrity, Contour and Intact Borders
B. CT Scan: Disc integrity

A

B. CT Scan: Disc integrity

66
Q

Image Interpretations - Disk integrity (MRI or CT Scan)

It is used to check posterior disk margins on sagittal and axial views, evaluate disc height and hydration of nucleus pulposus using T2 weighted imaging, and check posterolateral margins on axial views.

A. MRI: Disk Integrity, Contour and Intact Borders
B. CT Scan: Disc integrity

A

A. MRI: Disk Integrity, Contour and Intact Borders

Note: The central portion of the disc appears white on T2, representing the nucleus pulposus (made up mostly of water)

67
Q

Image Interpretations - Soft Tissues (MRI or CT Scan)

  1. For assessing paravertebral soft tissues for edema due to trauma, neoplasms, or infection.
  2. For assessing prevertebral soft tissues on sagittal view, if there is edema d/t trauma
    infections, or hematoma.
  3. To check integrity of ligaments and spinal cord, especially after trauma to check for compression and edema.

A. MRI
B. CT Scan

A
  1. A
  2. B
  3. A
68
Q

Image Interpretations - MRI or CT Scan

  1. Bone bruises or marrow edema is seen on T2 weighted sequences
  2. Shows cancellous bone as less dense vertebral bodies
  3. Used to assess for any destruction due to disease or infection from a localized process or an extension from adjacent tissues

A. MRI Bone Signal
B. CT Scan Bone Density
C. Both

A
  1. A
  2. B
  3. C
69
Q

Image Interpretations - MRI or CT Scan

  1. Cortical bone is white (most dense)
  2. There is no bone or soft tissue windowing present
  3. Pedicle, transverse processes, and spinous processes (posterior ring structures) are white

A. MRI Bone Signal
B. CT Scan Bone Density
C. Both

A
  1. B
  2. A
  3. B
70
Q

Image Interpretations - MRI or CT Scan

  1. Check for narrowing or encroachment on the central canal or lateral recess, which indicates neural impingement
  2. Look for effacement (indentation from adjacent structure) of the thecal sac that may be from posterior vertebral endplate, disc, arthritic facet joints, free fragments, or thickened ligaments

A. MRI: Canal Space/CNS
B. CT Scan: Canal Space

A
  1. B (can be seen in the axial cut)
  2. A
71
Q

Image Interpretations - MRI or CT Scan

  1. Check for free fragments, signifying a fracture, extruded disc, or infection
  2. Check the canal space in sagittal and axial views

A. MRI: Canal Space/CNS
B. CT Scan: Canal Space

A
  1. B
  2. A

(3) Musculoskeletal Imaging (25 decks)

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